{"id":208,"date":"2014-07-29T11:29:05","date_gmt":"2014-07-29T11:29:05","guid":{"rendered":"http:\/\/209.151.87.121\/~fomes\/iom\/?p=208"},"modified":"2016-03-16T20:11:40","modified_gmt":"2016-03-16T20:11:40","slug":"lian-how-white-pepper","status":"publish","type":"post","link":"https:\/\/www.outbreakmuseum.com\/mobile\/salmonella-rissen\/lian-how-white-pepper\/","title":{"rendered":"Lian How White Pepper"},"content":{"rendered":"\n<table id=\"tablepress-17\" class=\"tablepress tablepress-id-17\">\n<thead>\n<tr class=\"row-1\">\n\t<th class=\"column-1\"><b>Outbreak:<\/b> Lian How White Pepper<\/th>\n<\/tr>\n<\/thead>\n<tbody class=\"row-striping\">\n<tr class=\"row-2\">\n\t<td class=\"column-1\"><b>Product:<\/b> White Pepper<\/td>\n<\/tr>\n<tr class=\"row-3\">\n\t<td class=\"column-1\"><b>Investigation Start Date:<\/b> 03\/02\/2009<\/td>\n<\/tr>\n<tr class=\"row-4\">\n\t<td class=\"column-1\"><b>Location:<\/b> OR, CA, NV, WA<\/td>\n<\/tr>\n<tr class=\"row-5\">\n\t<td class=\"column-1\"><b>Etiology:<\/b> <i>Salmonella<\/i> Rissen<\/td>\n<\/tr>\n<tr class=\"row-6\">\n\t<td class=\"column-1\"><b>Earliest known case onset date:<\/b> 11\/01\/2008<\/td>\n<\/tr>\n<tr class=\"row-7\">\n\t<td class=\"column-1\"><b>Latest case onset date:<\/b> 05\/27\/2009<\/td>\n<\/tr>\n<tr class=\"row-8\">\n\t<td class=\"column-1\"><b>Confirmed \/ Presumptive Case Counts:<\/b> 87 \/ 0<\/td>\n<\/tr>\n<tr class=\"row-9\">\n\t<td class=\"column-1\"><b>Positive Samples (Food):<\/b> 33<\/td>\n<\/tr>\n<tr class=\"row-10\">\n\t<td class=\"column-1\"><b>Hospitalizations:<\/b> 8<\/td>\n<\/tr>\n<tr class=\"row-11\">\n\t<td class=\"column-1\"><b>Deaths:<\/b> 0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<!-- #tablepress-17 from cache -->\n<div id=\"metaslider-id-228\" style=\"width: 100%; margin: 0 auto;\" class=\"ml-slider-3-99-0 metaslider metaslider-flex metaslider-228 ml-slider ms-theme-default\" role=\"region\" aria-label=\"Pepper 2009-056\" data-width=\"400\">\n    <div id=\"metaslider_container_228\">\n        <div id=\"metaslider_228\">\n            <ul class='slides'>\n                <li style=\"display: none; width: 100%;\" class=\"slide-1842 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-06 02:07:41\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/IMG_2293-1024x768-e1425607834144-400x200.jpg\" height=\"200\" width=\"400\" alt=\"Tray of accoutrements for Ph\u1edf (Vietnamese noodle soup) including a shaker of the infamous Lian How white pepper.\" class=\"slider-228 slide-1842 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">Tray of accoutrements for Ph\u1edf (Vietnamese noodle soup) including a shaker of the infamous Lian How white pepper.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-1841 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-06 02:07:40\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/IMG_2292-1024x768-e1425607851444-400x200.jpg\" height=\"200\" width=\"400\" alt=\"Bulk spice storage of Lian How products at a restaurant.\" class=\"slider-228 slide-1841 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">Bulk spice storage of Lian How products at a restaurant.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-1795 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-06 02:06:33\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/Salmonella-Rissen-Pepper-flier-11203-791x1024-e1425608265599-400x200.jpg\" height=\"200\" width=\"400\" alt=\"Recall notice for many Lian How products, including white and black ground pepper.\" class=\"slider-228 slide-1795 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">Recall notice for many Lian How products, including white and black ground pepper.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-648 ms-image \" aria-roledescription=\"slide\" data-date=\"2014-09-08 17:20:36\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2014\/09\/2009-056G-e1425546358263-400x200.jpg\" height=\"200\" width=\"400\" alt=\"Lian How white and black pepper containers that yielded positive Salmonella cultures; they now live in the museum.\" class=\"slider-228 slide-648 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">Lian How white and black pepper containers that yielded positive Salmonella cultures; they now live in the museum.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-232 ms-image \" aria-roledescription=\"slide\" data-date=\"2014-07-29 11:40:49\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2014\/07\/White-Pepper1-e1425547261333-400x200.jpg\" height=\"200\" width=\"400\" alt=\"Up close shot of the contaminated Lian How ground white pepper.\" class=\"slider-228 slide-232 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">Up close shot of the contaminated Lian How ground white pepper.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-233 ms-image \" aria-roledescription=\"slide\" data-date=\"2014-07-29 11:40:51\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2014\/07\/White-Pepper2-e1425547239986-400x200.jpg\" height=\"200\" width=\"400\" alt=\"An orange added to illustrate the actual size of a 5lb. container of ground pepper.\" class=\"slider-228 slide-233 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">An orange added to illustrate the actual size of a 5lb. container of ground pepper.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-1886 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-14 18:54:45\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/Picture1-400x200.png\" height=\"200\" width=\"400\" alt=\"The epidemic curve for S. Rissen white pepper outbreak; note date of recall and slow dissipation of cases are products are slowly identified in use at restaurant.\" class=\"slider-228 slide-1886 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">The epidemic curve for S. Rissen white pepper outbreak; note date of recall and slow dissipation of cases are products are slowly identified in use at restaurant.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-1887 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-14 18:54:47\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/Picture2-400x200.png\" height=\"200\" width=\"400\" alt=\"A graph depicts the background rate of the most common Salmonella serotype (Enteritidis) and the extremely low background rate of Salmonella Rissen infections in the United States.\" class=\"slider-228 slide-1887 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">A graph depicts the background rate of the most common Salmonella serotype (Enteritidis) and the extremely low background rate of Salmonella Rissen infections in the United States.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-1888 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-14 18:54:50\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/Picture3-400x200.png\" height=\"200\" width=\"400\" alt=\"Though a rare serotype, Salmonella Rissen did trend upward in the United States two years before this outbreak began.\" class=\"slider-228 slide-1888 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">Though a rare serotype, Salmonella Rissen did trend upward in the United States two years before this outbreak began.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-1889 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-14 18:54:52\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/Picture4-400x200.png\" height=\"200\" width=\"400\" alt=\"List of ingredients.\" class=\"slider-228 slide-1889 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">List of ingredients.<\/div><\/div><\/li>\n                <li style=\"display: none; width: 100%;\" class=\"slide-2001 ms-image \" aria-roledescription=\"slide\" data-date=\"2015-03-27 17:56:02\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/IMG_0239-400x200.jpg\" height=\"200\" width=\"400\" alt=\"One case had Salmonella cultured from an amputated toe; a replica exists in the museum.\" class=\"slider-228 slide-2001 msDefaultImage\" \/><div class=\"caption-wrap\"><div class=\"caption\">One case had Salmonella cultured from an amputated toe; a replica exists in the museum.<\/div><\/div><\/li>\n            <\/ul>\n        <\/div>\n        \n    <\/div>\n<\/div>\n\n<table id=\"tablepress-58\" class=\"tablepress tablepress-id-58\">\n<thead>\n<tr class=\"row-1\">\n\t<th class=\"column-1\">Outbreak Summary:<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr class=\"row-2\">\n\t<td class=\"column-1\"><i>Salmonella<\/i>  Rissen is a very rare serotype in the US.  When Oregon, California, and Nevada all reported it within days of each other, it began a coordinated investigation between those states (later to be joined by Washington and Idaho). This outbreak focused FDA attention on the role spices may play in salmonellosis outbreaks. Additionally, a large proportion of cases either had urine isolates or no gastrointestinal symptoms, making interviewing about food histories much more complicated.<br \/>\n<br \/>\n<ul><li>\u2022 <a href=\"http:\/\/www.outbreakmuseum.com\/mobile\/wp-content\/uploads\/2015\/03\/Salmonella-Rissen-cluster-HGQ.pdf\" target=\"_blank\">Outbreak questionnaire (PDF)<\/a><\/li><ul><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<!-- #tablepress-58 from cache -->\n\n<table id=\"tablepress-79\" class=\"tablepress tablepress-id-79\">\n<thead>\n<tr class=\"row-1\">\n\t<th class=\"column-1\">Details:<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr class=\"row-2\">\n\t<td class=\"column-1\"><b>Background:<\/b><br \/>\n<i>Salmonella<\/i> Rissen is a very rare serotype in the U.S. with approximately 6 cases\/year; in 2006 there was a sizable jump to 18 cases. Rissen is a fairly common serotype in Thailand, however; it is commonly associated with pork and chicken products.<br \/>\n<br \/>\nOn March 2, 2009, the Nevada State Public Health Laboratory posted a notification of a local cluster of <i>Salmonella<\/i> Rissen; CA and OR state health departments responded the same day to report similar local clusters\u2014definitely above the expected annual baseline. In fact, this was the first reported outbreak of <i>Salmonella<\/i> Rissen in the United States. Washington and Idaho would later join the investigation with locally reported cases. CA and NV cases were clusters in the San Francisco Bay and Carson City\/Reno areas, respectively.<br \/>\n<br \/>\n<b>Methods and Results:<\/b><br \/>\nBy consensus, cases with an identifiable onset date were interviewed with shotgun questionnaires. CDC reported that the only PFGE match in the PulseNet database was an FDA report of an isolate from Vietnamese black peppercorns in 2006. Although the significance of this finding was uncertain, we were aware of it and added pepper-related questions in all interviews. <br \/>\n<br \/>\nOregon noted that they had one case who was Vietnamese and another who frequently ate at Vietnamese restaurants\u2014fairly tenuous but about all we had to start with. An absence of travel histories implied a commercial product distributed primarily or exclusively in the West. <br \/>\n<br \/>\nAn extraordinary proportion of cases (63%) lacked what we could call a \u201cclean\u201d onset date\u2014they either had vague symptoms going back for an indefinite period or had only urine isolates, sometimes with no referable GI symptoms. <br \/>\n<br \/>\nCases broke out into three distinct populations:<br \/>\n<br \/>\n<ul><li>\u2022\t Approximately half of the cases either had exposure to Asian restaurants or foods or had Asian surnames who cooked traditionally Asian foods at home (Generally younger and healthy)<\/li><br \/>\n<li>\u2022 Cases exposed to same large casino buffet in Nevada (exposures occurred between 12\/08-2\/09)<\/li><br \/>\n<li>\u2022 35% of cases were hospitalized prior to or during time of specimen collection (generally older with underlying health conditions); they were at different facilities all under the same HMO organization<\/li><\/ul>At least 18 hypothesis-generating interviews were conducted using a hybrid of the Oregon shotgun and other more open-ended questions to explore longer time periods and more vague food exposures. Instead of using the standard time period of 7 days to go back and assess foods consumed prior to illness, we expanded the question over weeks and sometimes months of time; so many cases had little or no GI symptoms we wanted to cast a wide net when asking about exposures.<br \/>\n<br \/>\nNothing strongly suggestive emerged from those analyses other than the obvious clustering of NV and CA cases who had visited and eaten at Casino A in Reno. Efforts to identify common foods there foundered on the combination of poor recall and all-you-can-eat buffet overload. Some product testing was attempted, but initial results were all negative, including black pepper. NV initially suspected cilantro to be the culprit and were waiting to get confirmation that a buffet reservation had contained it at an ingredient; the decision was made not to test the black and white ground pepper that had been collected from the buffet in the first round of testing. All buffet ingredients that were initially tested came back negative.<br \/>\n<br \/>\n<ul><li> o\t Bean sprouts: 33% cases vs. 12% FoodNet;<\/li><li>&nbsp;&nbsp;&nbsp;&nbsp;\u2013OR 3.8, exact 95% CI 0.8-14.5, p=0.04<\/li><li>&nbsp;&nbsp;&nbsp;&nbsp;\u2013Cumulative (binomial) probability = 0.0154<\/li><li> o \tCilantro: 55% cases vs. 35% FoodNet;<\/li><li>&nbsp;&nbsp;\t&nbsp;&nbsp;\u2013OR 2.3, exact 95% CI 0.6-9.5, p=0.20<\/li><li>&nbsp;&nbsp;\t&nbsp;&nbsp;\u2013Cumulative (binomial) probability = .0597<\/li><li> o \tBlack pepper: 67% cases, no FoodNet data available<\/li><\/ul>Oregon decided to pursue brute force testing at two different restaurants frequented by one case (i.e., not really \u201cimplicated\u201d in any way). This case had a urine isolate of <i>Salmonella<\/i> Rissen that was tested as follow up to a urinary tract infection and only reported one instance of loose stools (i.e., diarrhea); the case ate the named restaurant in the 3 days before illness. Food and spice samples were collected and split between IEH Laboratories in Seattle and the Oregon State Public Health Laboratory. Both labs isolated <i>Salmonella<\/i> Rissen from an open 5# container of Lian How brand white pepper collected at a Chinese\/Vietnamese restaurant where the case added white pepper from a shaker into Ph\u1edf (Vietnamese noodle soup). The Oregon PHL also recovered Rissen from a similar and adjacent container of black pepper.<br \/>\n<br \/>\nCalifornia Food and Drug Branch and the FDA worked with Union International Food Co. (Union City CA), which quickly led to a \u201cvoluntary\u201d recall of Lian How and Uncle Chen brand pepper products on March 30, 2009\u2014and soon expanded include everything that they packaged or prepared because of gross environmental contamination with <i>Salmonella<\/i>.<br \/>\n<br \/>\nWe worked with local and ODA environmental health staff to trace product distribution in Oregon and to reach out to restaurant operators who may have received the product. Language barriers and other considerations made us chary of relying solely on the media or the efforts of product distributors.<br \/>\n<br \/>\nThe final official tally was 87 cases in OR, WA, ID, NV, and CA; eight of the cases were Oregon residents. Clean onset dates occurred between 12\/09\/2008 and 04\/29\/2009 and could only be establish for 32 (37%) of cases. Rissen was isolated from stool specimen in 54% of the cases and from urine specimen in 39% of the cases. Ages ranged from 5 months to 94 years old with a median of 52 years old. Females accounted for 64% of the cases. Eight people were hospitalized due to GI illness (in all states).<br \/>\n<br \/>\nQuantitative testing of three white pepper samples (recovered from 3 different Oregon restaurants) was performed by IEH Laboratories; results were 14 MPN\/g, 2,400 MPN\/g, and 14,900 MPN\/g.<br \/>\n<br \/>\n<b>Conclusions<\/b><br \/>\nContaminated white pepper was the cause of this outbreak. The positive black pepper sample was never replicated at any other lab and may have resulted from cross-contamination (most likely at the restaurant).<br \/>\n<br \/>\nThis outbreak (and the later Daniele salami outbreak) has focused FDA attention on the role spices may play in salmonellosis outbreaks; there are ongoing efforts in this arena.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<!-- #tablepress-79 from cache -->\n<p><a href=\"https:\/\/www.outbreakmuseum.com\/mobile\/exhibits\/\"><strong>Back to Outbreak Exhibits<\/strong><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Back to Outbreak Exhibits<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":true,"template":"","format":"standard","meta":{"footnotes":""},"categories":[20],"tags":[81,77,82,80,87,88,95,79,109,78],"class_list":["post-208","post","type-post","status-publish","format-standard","hentry","category-salmonella-rissen","tag-acute-and-communicable-disease-prevention","tag-dr-bill-keene","tag-fomes","tag-integrated-food-safety-center-of-excellence","tag-international-outbreak-museum","tag-iom","tag-lian-how-white-pepper","tag-oregon-health-authority","tag-salmonella-rissen","tag-tribute"],"_links":{"self":[{"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/posts\/208","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/comments?post=208"}],"version-history":[{"count":9,"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/posts\/208\/revisions"}],"predecessor-version":[{"id":2076,"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/posts\/208\/revisions\/2076"}],"wp:attachment":[{"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/media?parent=208"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/categories?post=208"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.outbreakmuseum.com\/mobile\/wp-json\/wp\/v2\/tags?post=208"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}